2D ECHO Basics

2D ECHO BASICS

1. ECHO Echo is something you experience all the time. If you shout into a well, the echo comes back a moment later. The echo occurs because some of the sound waves in your shout reflect off a surface (either the water at the bottom of the well or the wall on the far side) and travel back to your ears. A similar principle applies in cardiac ultrasound . 2

2. HI S T O R Y Dr. Helmut Hertz of Sweden in 1953 obtained a commercial ultrasonoscope , which was being used for nondestructive testing. He then collaborated with Dr. Inge Edler who was a practicing cardiologist in Sweden. The two of them began to use this commercial ultrasonoscope to examine the heart. This collaboration is commonly accepted as the beginning of clinical echocardiography as we know it today .

3. GENERATION OF AN ULTRASOUND IMAGE Echocardiography (echo or echocardiogram) is a type of ultrasound test that uses high-pitched sound waves to produce an image of the heart. The sound waves are sent through a device called a transducer and are reflected off the various structures of the heart. These echoes are converted into pictures of the heart that can be seen on a video monitor.. There is no special preparation for the test .

4. GENERATION OF AN ULTRASOUND IMAGE The transducer transforms the echo (mechanical energy) into an electrical signal which is processed and displayed as an image on the screen. The conversion of sound to electrical energy is called the piezoelectric effect.

5. MACH I NES There are 5 basic components of an ultrasound scanner that are required for… Generation Display Storage of an ultrasound image . Pulse generator - applies high amplitude voltage to energize the crystals Transducer - converts electrical energy to mechanical (ultrasound) energy and vice versa Receiver - detects and amplifies weak signals Display - displays ultrasound signals in a variety of modes Memory - stores video display

6. THE TRANSDUCER

7. THE TRANSDUCER The transducer is responsible for both transmitting and receiving the ultrasound signal. The transducer consist of a electrode and a piezo -electric crystal whose ionic structure results in deformation of shape when exposed to an electric current.

8. THE TRANSDUCER Piezo electric(PE) crystals are composed of synthetic material such as barium titanate which when exposed to electric current from the electrodes, alternately expand and contract to create sound waves. When subjected to the mechanical energy of sound from a returning surface, the same PE element change the shape thereby generating an electrical signal detected by the electrodes.

9. INDICATIONS

10. STRUCTURAL

11. FUNCTIONAL

12. TYP E S

13. POSITION OF PATIENT

14. VIEWING THE HEART

15. Parasternal Long-Axis View (PLAX) Transducer position: left sternal edge; 2 nd – 4 th intercostal space Marker dot direction: points towards right shoulder Most echo studies begin with this view It sets the stage for subsequent echo views Many structures seen from this view

16. PARASTERNAL LONG AXIS VIEW

17. Parasternal Short Axis View (PSAX) Transducer position: left sternal edge; 2 nd – 4 th intercostal space Marker dot direction: points towards left shoulder(90 clockwise from PLAX view) By tilting transducer on an axis between the left hip and right shoulder, short axis views are obtained at different levels, from the aorta to the LV apex. Many structures seen 22

18. Short-axis views

19. Apical 4-Chamber View (AP4CH)

20. APICAL VIEW

21. Apical 2-Chamber View (AP2CH)

22. Sub–Costal 4 Chamber View(SC4CH) Transducer position: under the xiphisternum Marker dot position: points towards left shoulder. The subject lies supine with head slightly low (no pillow). With feet on the bed, the knees are slightly elevated Better images are obtained with the abdomen relaxed and during inspiration Interatrial septum, pericardial effusion, desc abdominal aorta

23. Sub–Costal 4 Chamber View(SC4CH)

24. Suprasternal View Transducer position: suprasternal notch Marker dot direction: points towards left jaw The subject lies supine with the neck hyperexrended . The head is rotated slightly towards the left The position of arms or legs and the phase of respiration have no bearing on this echo window Arch of aorta

25. ECHO TECHNIQUES

26. 2D- ECHO

27. M MODE

28. DOPPLER

29. Summary Of Echo Modalities And Their Main Uses

30. NORMAL VALUES

31. Some Other Normal Findings Mild tricuspid and mitral regurgitation (MR) are found in many normal hearts. Some degree of thickening of AV leaflets with ageing is normal without significant aortic stenosis . Mitral annulus (ring) calcification is sometimes seen in older subjects. It is often of no consequence but may be misdiagnosed as a stenosed valve, a vegetation (inflammatory mass), thrombus (clot) or myxoma (cardiac tumour ). It is important to examine the leaflets carefully. It may be associated with MR.

32. MITRAL VALVE

33. MS Changes in MV area with severity of MS Normal valve : 4–6 cm 2 Mild MS : 2–4 cm 2 Moderate MS : 1–2 cm 2 Severe MS : <1 cm 2 . Criteria for diagnosis of severe MS (many derived from Doppler) Measured valve orifice area <1 cm 2 Mean pressure gradient >10 mmHg Pressure half-time >200 ms Pulmonary artery systolic pressure >35 mmHg.

34. MR

35. AORTIC VALVE

36. AS

37. AS

38. AR

39. AR

40. TR

41. The peak Doppler velocities in normal adults

42. LV APICAL CLOT

43. HCM

44. DCMP

45. AMYLOIDOSIS

46. TISSUE DOPPLER IMAGING (TDI)

47. Pulmonary hypertension This is defined as an abnormal increase in PA pressure above : 30/20 mmHg (normal 25/10 mmHg ) Mean 20 mmHg at rest Mean 30 mmHg during exercise . In those aged over 50 years, PHT is the third most frequent cardiovascular problem after coronary artery disease and systemic hypertension. Echo is useful in assessing the underlying cause and severity of PHT, but echo examination can be technically more difficult since many of these individuals have underlying lung disease. This is especially true if the lungs are hyperinflated or there is pulmonary fibrosis.

48. The echo features of PHT M-mode Abnormal M-mode of the pulmonary valve leaflets with absent A-wave or mid-systolic notch Dilated RV with normal LV Abnormal IVS motion (‘right ventricularization ’ of IVS ) Underlying cause, e.g. MS (PA systolic pressure is an index of severity ).

49. 2-D echo Dilated PA (e.g. parasternal short-axis view at aortic level). The PA diameter should normally not be greater than aortic diameter RV dilatation and/or hypertrophy RA dilatation Abnormal IVS motion Underlying cause, e.g. MV or AV disease, ASD, VSD, LV dysfunction . Doppler This is the best method to assess PA systolic pressure using TR velocity (as described in Ch. 3), or short PA acceleration time as a surrogate of PHT.

50. PERICARDIAL EFFUSION

51. CAD / RWMA

52. INFECTIVE ENDOCARDITIS

53. VSD

54. ASD

55. Patent Foramen Of Ovale

56. Bicuspid Aortic Valve

57. TOF

58. IVC

59. IVC

60. IVC